Effect of Intravenous Chemotherapy Regimen on Globe Salvage Success Rates for Retinoblastoma Based on Disease Class-A Meta-Analysis.

To evaluate the relative efficacy of novel retinoblastoma treatments, eye classification-specific success rates for current standard-of-care intravenous chemotherapy regimens must be known. This meta-analysis included studies if: (1) patients received intravenous chemotherapy for retinoblastoma, (2) globe salvage data was reported, (3) only intravenous chemoreduction (with/without local consolidation) was used. The outcome measure was globe salvage success without need for salvage radiotherapy, subdivided by disease classification and chemotherapy regimen. Data from 27 studies (1483 eyes) were pooled. By Reese-Ellsworth classification, globe salvage rates were 85% (95%CI:73-92%) for Group I, 78% (95%CI:70-85%) for Group II, 68% (95%CI:56-78%) for Group III, 47% (95%CI:34-60%) for Group IV, and 35% (95%CI:26-45%) for Group V (Va: 35% [95%CI:21-54%]; Vb: 42% [95%CI:29-56%]; those without sub-classification: 31% [95%CI:19-47%]). By International Classification, globe salvage rates were 93% (95%CI:80-97%) for Group A, 83% (95%CI:73-89%) for Group B, 73% (95%CI:54-86%) for Group C, 40% (95%CI:31-51%) for Group D, and 19% (95%CI:5-50%) for Group E. Standard carboplatin-etoposide-vincristine out-performed two-drug regimens (odds ratio (OR) = 1.9 (95%CI:1.3-3.0) for Groups I-IV and OR = 2.1 (95%CI:1.3-3.4) for Group V; p = 0.002 for each). For eyes with diffuse vitreous seeds (Vb), an enhanced regimen out-performed standard chemotherapy (OR = 2.4 [95%CI:1.3-4.7]; p = 0.004). In conclusion, two-drug regimens were less effective for all eyes, whereas enhanced regimens were more effective for eyes with vitreous seeds. Novel therapies can now be compared to these baseline globe salvage rates.

Association Between Ophthalmologist Age and Unsolicited Patient Complaints.

IMPORTANCE: Understanding the distribution of patient complaints by physician age may provide insight into common patient concerns characteristic of early, middle, and late stages of careers in ophthalmology. Most previous studies of patient dissatisfaction have not addressed the association with physician age or controlled for other characteristics (eg, practice setting, subspecialty) that may contribute to the likelihood of patient complaints, unsafe care, and lawsuits. OBJECTIVE: To assess the association between ophthalmologist age and the likelihood of generating unsolicited patient complaints (UPCs) among a cohort of ophthalmologists. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study with variable duration of follow-up. The study assessed time to first complaint between 2002 and 2015 in 1342 attending ophthalmologists or neuro-ophthalmologists who had graduated from medical school before 2010 and were affiliated with an organization that participates in Vanderbilt University Medical Center's Patient Advocacy Reporting System. Participants were stratified into 5 age bands and were followed up from the time of their employment to receipt of their first complaint. Trained coders categorized UPCs into 34 specific types under 6 major categories. MAIN OUTCOMES AND MEASURES: Time to first recorded complaint. Multivariable Cox proportional hazards model was used to measure the association between time to first complaint and ophthalmologist age after adjustment for predetermined covariates. RESULTS: The median physician age was 47 years, with 9% who were 71 years or older. The cohort was 74% male, 90% held MD degrees, and 73% practiced in academic medical centers. The mean follow-up period was 9.8 years. Ophthalmologists older than 70 years had the lowest complaint rate (0.71 per 1000 follow-up days vs 1.41, 1.84, 2.02, and 1.88 in descending order of age band). By 2000 days of follow-up (or within 5.5 years), the youngest group had an estimated UPC risk of 0.523. By 4000 days (>10 years), participants in the older than 70 years age band had an estimated risk of UPC of only 0.364. The 2 youngest age bands were associated with a statistically significant shorter time to first complaint. Compared with those aged 71 years or older, the risk of incurring a UPC for those aged 41 to 50 years was 1.73-fold higher (hazard ratio [HR], 1.73; 95% CI, 1.21-2.46; P = .002). Similarly, participants aged 31 to 40 years had a 2.36 times higher risk of incurring a UPC (HR, 2.36; 95% CI, 1.64-3.40; P < .001). CONCLUSIONS AND RELEVANCE: This study suggests that older ophthalmologists are less likely to receive UPCs than younger ones. Although limitations in the study design could affect the interpretation of these conclusions, the findings may have practical implications for patient safety, clinical education, and clinical practice management.

Diffuse ocular and orbital inflammation after zoledronate infusion-case report and review of the literature.

Bisphosphonates have become a commonly used class of medications to treat osteoporosis and other bone diseases. Zoledronate (zoledronic acid) can be dosed annually via intravenous infusion, making it an appealing option for patients and physicians. We report the case of a 68-year-old woman who developed severe, unilateral, ocular inflammation, including corneal endotheliitis, anterior uveitis with hyphema, scleritis, and orbital inflammation beginning 12 hours after receiving her first zoledronate infusion. Symptoms escalated but ultimately resolved with topical steroids and high-dose systemic corticosteroids. To our knowledge, this is the first report of unilateral diffuse inflammation of the eye and orbit, including corneal inflammation developing within 12 hours of a first zoledronate infusion.

Stevens-Johnson Syndrome and Corneal Ectasia: Management and a Case for Association.

PURPOSE: To report the occurrence of corneal ectasia (ECT) in patients with history of Stevens-Johnson syndrome (SJS), and to make the case for an association between these 2 diagnoses. We also report the impact of prosthetic replacement of the ocular surface ecosystem (PROSE) treatment on visual acuity (VA) in these patients. DESIGN: Retrospective cohort study. METHODS: A manufacturing database of PROSE patients from 2002 to 2014 at Boston Foundation for Sight (BFS), a single-center clinical practice, was reviewed to identify patients with diagnoses of both SJS and ECT. RESULTS: Nine patients were identified with diagnoses of both SJS and ECT. In each case, review of the medical record revealed that diagnosis of SJS preceded that of ECT. The prevalence of ECT in this population exceeded that in the general population (P < .0001). Videokeratography was available for 13 eyes in 7 patients; using Krumeich's classification of keratoconus, 3 eyes were found to be at stage 1, 3 at stage 2, 1 at stage 3, and 6 at stage 4. Sixteen of 18 eyes underwent PROSE treatment. Of these 16 eyes, initial median VA was 20/200 (range, count fingers to 20/20; logMAR 1.0). Median VA after PROSE customization was 20/30 (range, 20/60-20/15; logMAR 0.1761, P < .0025). CONCLUSIONS: ECT occurs at a higher-than-expected rate in patients with a history of SJS. PROSE treatment improves VA in these patients. The basis of the association between SJS and ECT is considered, as well as the role of plausible contributory factors such as corneal microtrauma and matrix metalloproteinases.

Racial Disparities in Corneal Transplantation Rates, Complications, and Outcomes.

Corneal transplantation is a common type of tissue transplantation that aims to improve vision or relieve pain. Given the immune privilege of the cornea, the primary graft often has a high success rate, approaching 90%. Despite the good overall outcome of corneal transplantation in various studies, the individual graft survival rate varies, depending on the preoperative diagnosis and donor and recipient factors. Race and ethnicity have been shown to be important in other types of organ transplantation. The aim of this study was to review the available ophthalmic literature regarding any differences in rates and outcomes of corneal transplantation based on ethnicity and race. A small body of evidence suggests that race might be an important risk factor for graft rejection and graft failure. More robust studies are needed to clarify these associations.

A Comprehensive Review of Sex Disparities in Symptoms, Pathophysiology, and Epidemiology of Dry Eye Syndrome.

INTRODUCTION: The etiology, frequency, manifestation, and treatment of dry eye syndrome are commonly influenced by sex and gender. MATERIALS AND METHODS: This study aims to review the differences in epidemiology, pathophysiology, and associated diseases between the sexes. The terms men and male and women and female are used interchangeably throughout the review to refer to biological sex. RESULTS: There are numerous objective and subjective markers of dry eye syndrome but not one diagnostic criterion. There are numerous associated conditions with dry eye syndrome varying from autoimmune to allergic. Large epidemiologic studies reviewed suggest that there does indeed exist a difference between dry eye symptoms between men and women, with women having dry eye signs and reporting dry eye symptoms more often than men. The increased prevalence in women could be correlated to an increased association with certain systemic diseases, specifically autoimmune diseases, and to hormonal variations. Several studies found equivocal data about prevalence of dry eye symptoms between men and women. DISCUSSION: Interpreting studies that investigate epidemiology, pathogenesis, and treatment of dry-eye conditions is complicated by the lack of universally adapted diagnostic criteria and standardized, specific diagnostic tests, and inter-study variability in the definition of dry eye syndrome.

Disparities in Vision Loss Due to Cataracts in Hispanic Women in the United States.

PURPOSE: To review the current literature on the prevalence of cataract in Hispanic females living in the United States. METHODS: Review relevant literature on cataract, eye disease, and health practices of Hispanics living in the U.S. RESULTS: Females comprise 64.5% of blind persons worldwide. Internationally, female gender is associated with lower awareness of cataract and other diseases of the eye and women are less likely to have cataract surgery than men in low- and middle-income countries. CONCLUSION: Hispanic women receive disparate care compared to their male counterparts. The etiology of this is likely multifactorial but possible contributors include genetics, gender roles, and personal healthcare decisions. Interventions to address this disparity should be targeted, efficient, and sustainable.

Disparities in Adherence to Screening Guidelines for Diabetic Retinopathy in the United States: A Comprehensive Review and Guide for Future Directions.

Diabetic retinopathy (DR) is the leading cause of new-onset blindness in American adults aged 20-74 years old. The number of diabetics living with diagnosed DR increased by 89%, from 4.06 million to 7.69 million, between 2000 and 2010. Projected numbers from the Vision Health Initiative by the CDC predict that the rate of DR will triple by 2050, from 5.5 million people living with DR to 16 million. Screening guidelines aim to detect cases early because the treatments for DR can reduce severe vision loss by up to 94%. However, adherence to these guidelines is quite low. It is estimated that more than half of patients with diabetes may fail to receive necessary screening. Risk factors for non-screening discussed in this study include low health literacy, lack of access to care, pregnancy, physician adherence to guidelines, unique factors present in different minority populations, gender and age disparities, and living in rural regions. This paper also aims to address potential interventions that may improve adherence rates.

Acute and Chronic Ophthalmic Involvement in Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis - A Comprehensive Review and Guide to Therapy. II. Ophthalmic Disease.

Our purpose is to comprehensively review the state of the art with regard to Stevens- Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), with particular attention to improving the management of associated ocular surface complications. SJS and TEN are two ends of a spectrum of immune-mediated disease, characterized in the acute phase by a febrile illness followed by skin and mucous membrane necrosis and detachment. Part I of this review focused on the systemic aspects of SJS/TEN and was published in the January 2016 issue of this journal. The purpose of Part II is to summarize the ocular manifestations and their management through all phases of SJS/TEN, from acute to chronic. We hope this effort will assist ophthalmologists in their management of SJS/TEN, so that patients with this complex and debilitating disease receive the best possible care and experience the most optimal outcomes in their vision and quality of life.

Unsolicited Patient Complaints in Ophthalmology: An Empirical Analysis from a Large National Database.

PURPOSE: The number of unsolicited patient complaints about a physician has been shown to correlate with increased malpractice risk. Using a large national patient complaint database, we evaluated the number and content of unsolicited patient complaints about ophthalmologists to identify significant risk factors for receiving a complaint. DESIGN: Retrospective cohort study. PARTICIPANTS: Ophthalmologists, nonophthalmic surgeons, nonophthalmic nonsurgeons. METHODS: We analyzed 2087 unsolicited or spontaneous complaints reported about 815 ophthalmologists practicing in 24 academic and nonacademic organizations using the Patient Advocacy Reporting System (PARS). Complaints against 5273 nonophthalmic surgeons and 19487 nonophthalmic nonsurgeons during the same period were used for comparison. Complaint type profiles were assigned using a previously validated standardized coding system. We (1) described the distribution of complaints against ophthalmologists; (2) compared the distribution and rates of patient complaints about ophthalmologists with those of nonophthalmic surgeons and nonophthalmic nonsurgeons in the database; (3) analyzed differences in complaint type profiles and quantity of complaints by ophthalmic subspecialty, practice setting, physician gender, medical school type, and graduation date; and (4) identified significant risk factors for high numbers of unsolicited patient complaints after adjusting for other covariates. MAIN OUTCOME MEASURES: Unsolicited patient complaints. RESULTS: Ophthalmologists had significantly fewer complaints per physician than other nonophthalmic surgeons and nonsurgeons. Sixty-three percent of ophthalmologists had 0 complaints, whereas 10% of ophthalmologists accounted for 61% of all complaints. Ophthalmologists from academic centers, female ophthalmologists, and younger ophthalmologists had significantly more complaints (P < 0.01), and general ophthalmologists had significantly fewer complaints than subspecialists (P < 0.05). After adjusting for covariates using multivariable analysis, working at an academic center was a statistically significant risk factor (adjusted relative risk, 1.82; 95% confidence interval, 1.36-2.43; P < 0.001). CONCLUSIONS: Ophthalmologists had significantly fewer complaints than nonophthalmic surgeons and nonophthalmic nonsurgeons, and by implication may have a lower malpractice risk as a group. Nevertheless, a small number of ophthalmologists generated a disproportionate number of complaints. Working at an academic center was a significant independent risk factor for having more patient complaints. Further research is needed to clarify the underlying reasons for this association and to identify interventions that may decrease this risk.

Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis--A Comprehensive Review and Guide to Therapy. I. Systemic Disease.

The intent of this review is to comprehensively appraise the state of the art with regard to Stevens Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), with particular attention to the ocular surface complications and their management. SJS and TEN represent two ends of a spectrum of immune-mediated, dermatobullous disease, characterized in the acute phase by a febrile illness followed by skin and mucous membrane necrosis and detachment. The widespread keratinocyte death seen in SJS/TEN is rapid and irreversible, and even with early and aggressive intervention, morbidity is severe and mortality not uncommon. We have divided this review into two parts. Part I summarizes the epidemiology and immunopathogenesis of SJS/TEN and discusses systemic therapy and its possible benefits. We hope this review will help the ophthalmologist better understand the mechanisms of disease in SJS/TEN and enhance their care of patients with this complex and often debilitating disease. Part II (April 2016 issue) will focus on ophthalmic manifestations.

Treatment of ankyloglossia for reasons other than breastfeeding: a systematic review.

BACKGROUND AND OBJECTIVE: Children with ankyloglossia, an abnormally short, thickened, or tight lingual frenulum, may have restricted tongue mobility and sequelae, such as speech and feeding difficulties and social concerns. We systematically reviewed literature on feeding, speech, and social outcomes of treatments for infants and children with ankyloglossia. METHODS: Medline, PsycINFO, Cumulative Index of Nursing and Allied Health Literature, and Embase were searched. Two reviewers independently assessed studies against predetermined inclusion/exclusion criteria. Two investigators independently extracted data on study populations, interventions, and outcomes and assessed study quality. RESULTS: Two randomized controlled trials, 2 cohort studies, and 11 case series assessed the effects of frenotomy on feeding, speech, and social outcomes. Bottle feeding and social concerns, such as ability to use the tongue to eat ice cream and clean the mouth, improved more in treatment groups in comparative studies. Supplementary bottle feedings decreased over time in case series. Two cohort studies reported improvement in articulation and intelligibility with treatment. Other benefits were unclear. One randomized controlled trial reported improved articulation after Z-frenuloplasty compared with horizontal-to-vertical frenuloplasty. Numerous noncomparative studies reported speech benefits posttreatment; however, studies primarily discussed modalities, with outcomes including safety or feasibility, rather than speech. We included English-language studies, and few studies addressed longer-term speech, social, or feeding outcomes; nonsurgical approaches, such as complementary and alternative medicine; and outcomes beyond infancy, when speech or social concerns may arise. CONCLUSIONS: Data are currently insufficient for assessing the effects of frenotomy on nonbreastfeeding outcomes that may be associated with ankyloglossia.